Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> `�sconsin7302 <br /> See reverse side for instructions for completing this application Madison,WP5o3Box 7302 <br /> Personal information you provide may be used for secondary purposes <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on pqper not less than 8-1/2 x 11 inches in size. <br /> County State SanitaryPermit Number Check if revision to p vious application State Plan I.D.Number <br /> e4/N e 3 (.b .-# R75a7 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name t Property Location <br /> p/1 eJ 1/4 1/4,S 7 T X6,14,R E(or) <br /> Property Owner's Mailing Addressr t Number Block Number <br /> �� y33 V':t 3 <br /> City,State Zip Code Phone Number Sub 'vision Name or CSM Number <br /> /n nJ 3 Sa a ( GS/ ) 5'3L �yS� fes&'� <br /> II.Type of Building: (check one) ❑city <br /> 91 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Public/Commercial(describe use):_ O Own of <br /> ❑State-Owned G dr <br /> Nearest Road <br /> 60/ C�4 <br /> Parcel Tait Numbers) O f 30 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) I. New 2. U Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> A-Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 360 Y52— , 7 9L f9S, 9A/- 77, <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks I Tanks <br /> sc 7,50 S 0 ,g, 1:1 ❑ 1:1 ❑ <br /> NM <br /> say ❑s�o 1:1 ° <br /> VI I.Res1fonsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> ale- Z"f'le 3y9 -72.s�L <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W72IX5-W,72-- <br /> IX' <br /> .County/Department Use Only <br /> ❑Disapproved J Sanitary Permit Fee(Includes Groundwater Date Issued Issuing a tgnature stamps) <br /> Approved 0 Owner Given Initial Adverse Surcharge Fee) <br /> DeterminationA <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />